Swing Mandibulotomy Access to Deep Lobe Parotid Tumors Case Reviews

Pleomorphic adenoma is the most common salivary gland tumor [1]. Most of these tumors originate in the superficial lobe with few involving the deeper lobe with medial extensions in to the adjacent parapharyngeal space (PPS) [2]. These tumors are generally considered to be benign even if the lesion presents with varied histological features due to different components with myxoid or, chondroid components. The main characteristics include its high recurrence rate and not infrequent malignant transformation. Most cases present as asymptomatic swellings without involving the facial nerve until there is substantial growth and impingement of the facial nerve. Often, onset of a facial nerve deficit, changes in consistency, rapid growth, and pain are the signs for the malignant transformation of the lesion. The histological variation of the tumor along with its particular location poses difficulty in its accessibility for adequate removal of the tumor. Because of the difficulty involved in getting into the parapharyngeal space (PPS), different approaches have been described including the transcervical, the first approach, described by Morfit HM [3], transcervical-transparotid, the most widely used, helpful in PPS tumors originating in the parotid deep lobe, transpalatal or, transoral, described by Ehrlich H [2] and limited to small non-vascular tumors, transmandibular with mandibular osteotomy being described as a complement to the other approaches in order to improve and increase access to the parapharyngeal space (PPS), Ariel IM et al. [4] were the first to propose opening the jaw to enter the PPS with numerous variations in the procedure being described later [5,6], and lastly, the orbito-zygomatic approach to the middle cranial fossa described by Fisch U [7] to give access to PPS tumors affecting the temporal bone or, relatively larger tumors reaching the base of skull. Thus, it becomes of utmost significance to select the right surgical approach for such kind of cases balancing maximum exposition and complete and safe removal of the tumor with minimal functional and esthetic morbidity.